Provider Demographics
NPI:1245483569
Name:SIEM, MICHAEL SHANE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:SIEM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:1035 116TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4604
Practice Address - Country:US
Practice Address - Phone:425-688-5573
Practice Address - Fax:425-688-5464
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60056591363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0377413OtherL&I-RADIA KING COUNTY
WA0377409OtherL&I-RADIA REST OF WA
WA0377427OtherL&I-SWEDISH RADIA EDMONDS
WA2011887Medicaid
WA0377418OtherL&I-EVERGREEN RADIA